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Are We Helping or Hurting, by Treating??!!

Issue: Vol.5, No.4 - October 2006

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Article Type: Editorial

  1. Dr C. John Mathews
    PhD, MB, FRCS, FRCSI
  2. Dr M Jarallah
    FRCS, FICS

Are We Helping or Hurting, by Treating??!!

 

 

Gastric cancers remain a death warrant to patients in spite of long standing scientific research and a much-improved understanding about the condition.  There are over 7000,000 new cases worldwide every year and overall and outcome from the disease is abysmal.  The highest incidence is in Japan and South America with the lowest rates in USA and Western Europe.  Many third world countries bear significant financial burden from this condition, on their national budgets.  Relatives of patients not only end up losing their loved ones, but also in irreparable economic crisis, resulting from expensive private health care, due to inefficient national health systems.

 

Japan is well known to produce excellent results for gastric cancer sufferers and some reports claim five-year survival of up to 90% after surgery.  Other countries including many developed nations with efficient national health services lag behind on this front by a long way.  The reasons for such vast difference in outcome are multiple and some experts attribute even difference in biological behavior of the disease as one.  Nevertheless, there is no doubt that well coordinated mass screening programmes to diagnose the disease in very early stage is the major factor.  Many cancers are detected when they are confined to the mucosa and have given the patient hardly any symptom.

 

If Japan can achieve this, why do others fail to match this?  Population endoscopic screening for cancer of the stomach is deemed not to be cost effective in these countries, mainly because of the low prevalence rate and therefore, small ‘yield’ for screening.  It is wrong to put a price tag on anyone’s life but researchers have proposed at some generally accepted outcome measures like cost per life saved and cost per quality-adjusted life year to accept any screening methods cost effective.  The results of estimate of such measures in the case of gastric cancer do not justify the financial implications of it on the country.  It is beyond the scope of this article to go into further details regarding the above measures.

 

The second method to consider is, screening people at high risk.  Unfortunately even though there are many documented risk factors, the role they play in the aetiology of gastric cancer is not very clear.  Also a large percentage of people in the population belong to such groups at risk.  Dietary factors like smoked, salty and spicy food are consumed widely.  Smoking and alcohol consumption is widespread in third world countries and H pylon infection is a very common incidental finding at endoscopy.  Added to this is the small risk of major complications of endoscopic examination of the stomach like perforation and aspiration.  When the very small yield of positive diagnosis is included in this scenario, this method also has its serious limitations.  Nevertheless, a recent report from Singapore in this matter is encouraging.

 

The third and the last way of making an early diagnosis of Gastric cancer is early investigation of people with symptoms.  The symptoms are not path gnomonic and can be caused by a variety of other benign conditions.  Gastro-oesophageal reflux disease, peptic ulcer and biliary disease are some from a long list.  Therefore investigating all patients having such symptoms is neither fruitful nor safe.  Here is where, we clinicians need to pause and take a ling breadth.  Various scientific groups like the British society of endoscopy, have been helpful to the patients’ cause.  There are well-accepted guidelines to dictate how we should deal with an individual patient.  Gastric cancer is rare below the age of forty and the incidence dramatically rises around the sixth decade.  Therefore the primary care practitioners have a responsibility to think long and hard when they deal with patients in this age group with recent dyspepsia and other non-specific symptoms.  Other risk factors, if present, make the need for early investigations more obvious.

 

In summary, when dealing with such patients in whom early diagnosis make the difference between life and death, we have a duty to reach at a safe and correct diagnosis before treatment is offered.  Very frequently this will mean sending the patients to another expert or centre of excellence for necessary investigation and further management.

 

Unfortunately, especially in third world countries, where medical personnel claim to belong to a higher status than the ordinary people, practice is quite different.  Ignorance, lack of facilities and to some extent greed of some clinicians prevent delivery of proper standard of care to these patients.  Selfish motives of pharmaceutical companies help to lure some to prescribe strong medicines with impunity to their patients without reaching, rather looking for a correct diagnosis.  Life is not reproducible and any act to endanger it, be it through intentional action, or the lack of it, is criminal.  If individuals refuse a update themselves with modern theories in medicine and adhere to those, the respective medical councils and governments must have mechanisms in force to restrict such erratic behaviour.  We this also fails, we can only hope for the best, for the future.

 

 

 

C. John Mathews PhD, MB, FRCS, FRCSI, UK

Dr. M. Jarallah FRCS, FICS, KUWAIT

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